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Measles returns: Know worker immune status
Improve recordkeeping, immunize older workers
Make sure you know the measles immune status of your employeesand have ready access to the information. That is the message to employee health professionals contained in a recent public health advisory from the Centers for Disease Control and Prevention in Atlanta.
The advisory was prompted by an outbreak of measles in Arizona, which led hospitals on a paper chase and vaccination blitz as they sought to ensure the immunity of employees.
Optimally, vaccination information should be contained in an electronic database, not just in paper records, says Jane Seward, MD, MPH, deputy director of CDC's Division of Viral Diseases. "If they don't have records that can be immediately provided when an exposure occurs, it's a huge amount of work to round up that information," says Seward.
Meanwhile, the CDC may be on the verge of changing its recommendation for people born before 1957. While measles was a ubiquitous childhood disease for that generation, a small proportion remains non-immune. It would be prudent to conduct serologic testing or to give them one dose of the MMR (measles, mumps, rubella) vaccine, Seward says.
That is what would be recommended in the case of an outbreak. The 1998 recommendation states: "...although birth before 1957 is generally considered acceptable evidence of measles immunity, measles has occurred in some unvaccinated persons born before 1957 who worked in health-care facilities. Therefore, health care facilities should consider recommending a dose of MMR vaccine for unvaccinated workers born before 1957 who lack a history of measles disease or laboratory evidence of measles immunity."1
"It is a bit of a double message," she says. "You're considered immune, but if there's an outbreak, you're not. It's better to have the immunity status of everybody, including those born before 1957, with serological testing or physician-documented history of disease."
Testing employees during an outbreak often isn't practical, says Seward, because the employees need to be vaccinated as quickly as possible. A change in the recommendation will likely be proposed when two expert panels convene in June to discuss immunization and health care policythe Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee, Seward says.
Sick tourist from Switzerland
A tourist from Switzerland triggered an outbreak this winter when she came to the emergency department at Northwest Medical Center in Tucson. As of mid-April, 11 exposed people ranging in age from 10 months to 50 years had contracted measles. That included one susceptible health care worker.
Measles is airborne, and anyone in the same room with a measles patient could be infected, says Seward. "It's very, very highly infectious," she says. "It's a serious disease. People who get it typically do end up in health care settingsin emergency rooms, in outpatient [clinics] or likely hospitalized. Once that occurs, then there are a number of health care personnel who are exposed."
As many as 1,800 hospital employees were considered potentially exposed, and the hospital ultimately gave about 400 vaccinations, she says.
In another case, a hospital had electronic employee records only for those hired after 1990. They had to determine immune status for hundreds of other employees.
Employees are not the only ones who need verified immunity. Contract workers, volunteers, and any others who come into contact with patients should be vaccinated or have immunity against measles, she says.
It's important to take swift action by isolating patients with known or suspected measles. CDC advises health care providers to suspect measles in anyone with a "generalized maculopapular rash" that lasts three or more days, and who has a fever of 101 or greater and a cough, nasal congestion or conjunctivitis. The incubation period can range from 7 to 18 days, and immunocompromised patients may not exhibit the typical rash, CDC cautions.
Complications of measles can include encephalitis and pneumonia. The World Health Organization reports that an estimated 242,000 people died of complications from measles in 2006.
Although measles is not endemic in the United States, importations continue to occur. Ongoing outbreaks in Switzerland and Israel led to cases in New York, Virginia, Michigan and California.
"We need to be prepared until there's no measles in the world, and that's not likely to occur," says Seward. "Health care settings need to be prepared, and they need to remember that measles still exists."
Titering employees to check immune status
By requiring evidence of measles immunity at hire, the Marshfield (WI) Clinic avoids the difficulty of reviewing employee records each time a measles case occurs in Wisconsin, says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety.
"We titer all new employees. Any new employee that doesn't have a documentable immunity, we vaccinate again. Then we don't have to go through a hassle every time we have an outbreak," he says.
That is true even for employees who report previous two-dose vaccination or for those born before 1957, who are presumed to have had exposure to measles.
After the extra dose of vaccine, fewer than 10% fail to develop immunity, says Cunha. Those employees are considered to be non-responders.
"We send them a notice that we consider them non-immune and they have to be careful not to work with patients with measles," he says.
The titering of all employees is not a CDC recommendation, but it is a precautionary measure, says Cunha." Immunization does not equal immunity," he notes.
[Editor's note: A copy of the CDC Health Advisory on measles is available at www2a.cdc.gov/HAN/ ArchiveSys/ViewMsgV.asp?AlertNum=00273.]
1. Centers for Disease Control and Prevention. Measles, Mumps, and Rubella-Vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998; 47(RR-8): 1-57.